Health inspection·August 27, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure adequate supervision for one of three sampled residents (Resident1) when Resident 1, who requires a two-person assist, fell out of bed while one Certified Nursing Assistant (CNA) was repositioning the resident and providing a brief change.This failure resulted in Resident 1 sustaining intertrochanteric (thigh bone) fracture of left hip.Findings:During review of Residents 1's admission Record (general demographics information), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes (body has trouble controlling blood sugar), hypertension (high blood pressure), dependance on respirator (difficult to breathe on own, machine dependent). During a review of Resident 1's History and Physical (H&P), dated January 27, 2025, the H&P indicated, Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Seta (MDS - clinical assessment tool used in nursing homes that serves as a comprehensive summary of a resident's functional capabilities, health conditions, and care needs.) Section GG Functional Abilities, dated June 7, 2025, the MDS Section GG Functional Abilities indicated, .Toileting hygiene, Shower/bath self, Roll Left and Right=Dependent= Helper does All of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.During a review of Resident 1's Situation Background Assessment Recommendation (SBAR) notes dated July 29, 2025, at 5:22 AM, the SBAR indicated During rounds resident noted to slide from bed and struck head on oxygen concentrator and was lowered on to the ground by staff. Noted with open area to top of Left eye with scant bleeding. Noted with bruising to cheekbone and cheek. Transfer to acute to rule out fracture.During a review of Resident 1's X-ray (generate images of tissue and structure of body) report, dated July 29, 2025, the X-ray of the left hip shows displaced intertrochanteric fracture. The X-ray report also indicated PLAN: At this time, family is choosing to pursue nonsurgical management for left hip fracture, and they are listing his high propensity (natural tendency) to infections as a deterrent to surgery at this time.During a review of Resident 1's care plan dated June 25, 2024, the care plan indicated Resident 1 has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Activity Intolerance, Confusion, Limited Mobility, Limited ROM. INTERVENTIONS: BATHING/SHOWERING: The resident is totally dependent on (2) staff to provide(bath/shower).and as necessary. BED MOBILITY: The resident is substantial assistance on (2) staff for repositioning and turning in bed (Q2hrs) and as necessary.During an interview on August 27, 2025, at 1:20 PM, with CNA 1, CNA 1 stated, It's always a two (2) person assist to change the residents here in subacute. The CNAs help each other. If it is busy I have to wait, I cannot take the risk of doing the care alone. The nurse also helps if needed.During an interview on August 27, 2025, at 1:38 PM, with CNA 2, CNA 2 stated, In subacute, we always have 2 persons assist with ADLs, we have a buddy with another CNA, but we can always ask the nurses or Respiratory Therapist.During an (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555350 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)